We're sorry but you are not eligible for the program at this time, because you are pregnant.

We are sorry but you are not eligible for the program at this time, because you have previously participated in this or a related program.

We are sorry but you are not eligible for the program at this time, because you do not have PEIA PPB insurance.

We're sorry but you are not eligible for the program at this time, because your BMI is less than 25 and your waist circumference does not meet the required values for eligibility (35 inches or higher for women, 40 inches or higher for men).

Please allow 7 business days for your application to be processed. Once it is processed you will receive an
email response. If you have questions after the 7 days please call 1-866-688-7493.

Application Date:

MM-DD-YYYY

First Name:

*

Last Name:

*

How did you hear about the PEIA Weight Management Program?

Gender:

*

If you are female, are you currently pregnant?

YesNo*

Date of Birth:

*
MM-DD-YYYY

Current Weight:

*
pounds

Current Height:

*
feet inches

Waist Circumference:

*
Inches

BMI Score Calculation:

Do you have PEIA PPB insurance?

YesNo*

Have you ever participated in the PEIA Weight Management Program?

YesNo*

Have you ever had bariatric surgery (lap band or gastric bypass)?

YesNo

If you have had bariatric surgery in the past how many years ago did you have the
procedure?

Are you considering having bariatric surgery?

YesNo

What is the incident or trigger that prompted you to join the program?

Social Security Number:

*

Primary Cardholder SSN:

*

Primary Cardholder PEIA ID:

*

PEIA ID Numbers should start with 770.

Where do you currently work?

Are you a medicare recipient?

YesNo

Mailing Address:

Street:
*

City:
*
State:
*
Zip:
*

County:

Email:

*

For the phone numbers below please list only the numbers where you would be willing
to take our calls.

Home Phone:

Work Phone:

Mobile Phone:

We will need to reach you for scheduling appointments or other administrative tasks
during the hours of 9:00 AM to 5:00 PM. What is the best method to reach you for
these appointments?